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Frequently Asked Questions

Browse F.A.Q. Topics

Beneficiaries

  • Can a beneficiary enrolled in MississippiCAN change from one CCO to another?

    During the initial 90-day enrollment period, a member can change CCOs without restriction. Also, there will be an open enrollment period each year in which a member can change CCOs without restriction.

  • Will beneficiaries be allowed to disenroll from a plan if required specialized services are not available?

    Various “for cause” reasons for disenrollment will be allowed, such as: providers that do not (for religious or moral reasons) offer needed services; not all related services are available in the plan’s network; or the plan lacks providers experienced in dealing with the enrollee’s health care needs.

  • Can a CCO disenroll a beneficiary because their care is costing too much?

    A CCO cannot disenroll a beneficiary because of an adverse change in the beneficiary’s health status or because of the beneficiary’s utilization of medical services.

  • Will beneficiaries who are enrolled in the MississippiCAN program be responsible for copays?

    There will be no copayments for MississippiCAN members for services provided by the CCOs.

  • Will CCOs be marketing to beneficiaries?

    CCOs are not allowed to market directly to Medicaid beneficiaries prior to enrollment. All marketing of potential enrollees will be handled by the Division of Medicaid. The Division will be providing information about choice of CCOs and enrolling beneficiaries into their chosen CCO.

  • What if a beneficiary has a problem with the CCO?

    Each CCO has a grievance procedure. If the issue is not resolved satisfactorily through the CCO, the beneficiary has the right to a State Fair Hearing.

  • If a CCO does not authorize a covered service, will regular Medicaid pay for the CCO covered service?

    No.

  • What is the benefit of a beneficiary enrolling with a CCO?

    CCOs will be providing beneficiaries with specific care management and disease management for chronic conditions like diabetes, hypertension, HIV/AIDS, etc. Also, CCOs may offer extra benefits and other incentives.

  • Will beneficiaries get an identification card from the CCO when they enroll?

    Yes. Beneficiaries enrolled in a CCO will have an identification card from the CCO and a Medicaid identification card. It will be necessary to keep both cards.

  • If a beneficiary enrolls with a CCO, how will he or she get a ride to medical appointments if needed?

    Non-emergency transportation will continue to be provided by Medicaid. A beneficiary will call 1-866-331-6007 to make arrangements for a ride.

  • Will prescription drugs be one of the benefits offered by the CCOs?

    Yes.

  • Can a beneficiary choose a specialist as a PCP?

    Beneficiaries with disabling conditions, chronic illnesses, or children with special care needs may request that their PCP be a specialist.

  • Can a beneficiary enrolled in the MississippiCAN program continue to receive care from a provider who does not participate in any of the plans?

    Providers who do not join a CCO network will require authorization from the CCO for payment of services provided to a beneficiary enrolled in MississippiCAN. A beneficiary enrolled in the MississippiCAN program should seek treatment from a provider in the CCO network.

  • Will MississippiCAN replace a beneficiary’s Medicaid?

    The MississippiCAN program is part of the Mississippi Medicaid program. It is not a replacement.

  • Can a beneficiary in MississippiCAN change PCPs?

    Yes. The beneficiary should call Member Services of the CCO with which they are enrolled.

  • Will beneficiaries be allowed to select their primary care provider (PCP) within a CCO?

    Each beneficiary will be allowed to choose their PCP from the CCO network to the extent possible, reasonable and appropriate. If the beneficiary does not choose an available PCP, the CCO may assign the beneficiary a PCP.

  • Will beneficiaries have freedom of choice in determining the best plan for their needs?

    Yes.

  • How will it be ensured that beneficiaries who are blind or those with low literacy or limited English proficiency obtain information necessary to choose a plan?

    Enrollment information and materials will be developed to ensure all beneficiaries, including those with special needs, are fully informed of their choice of plans.

  • What consumer protections are being included in the MississippiCAN program?

    Members’ rights and protections are required, including the right to:

    • Receive needed information about the program;
    • Be treated with respect, dignity and privacy;
    • Receive information on available treatment options; participate in health care decisions;
    • Request copies of medical records; and
    • Be furnished services with an adequate delivery network, timely access, coordination and continuity of care, and other specified standards.

    Members’ protections will also be provided through access standards, care coordination requirements, quality management programs and detailed grievance and appeals procedures.

  • If a beneficiary enrolled in the MississippiCAN program loses eligibility, does he or she have to choose a CCO again?

    If the beneficiary regains Medicaid eligibility within 60 days, he or she will be reassigned to the same CCO he or she was in before. If the beneficiary regains Medicaid eligibility after 60 days, he or she will go through the complete enrollment process again.

  • If a beneficiary opts out of the MississippiCAN program but later decides that he or she wants join, does he or she have to wait until the next open enrollment period?

    No. A beneficiary in an eligible category may join at any time. A beneficiary may print the MississippiCAN enrollment form from the website or may call toll-free 1-800-421- 2408 and ask to be mailed a MississippiCAN enrollment packet.

  • Is it mandatory for beneficiaries to enroll in the MississippiCAN program?

    Although enrollment in the program is voluntary, the Division of Medicaid strongly encourages beneficiary participation. The MississippiCAN program will connect beneficiaries to a medical home and provide comprehensive care management programs for these targeted populations.

  • Can any Medicaid beneficiary enroll in the MississippiCAN program?

    Only Medicaid beneficiaries in the eligibility groups listed below can enroll in the MississippiCAN program.

    • Supplemental Security Income (SSI)
    • Disabled Child at Home
    • Working Disabled
    • Department of Human Services Foster Care
    • Breast/Cervical Group

Dental

  • What can a provider do to minimize missed appointments?

    These are suggestions only; they do not represent Medicaid policy. It is important to treat all Medicaid beneficiaries in the same manner as other non-Medicaid patients are treated:

    • Confirm appointments prior to the date of the appointment by sending a post card or calling a day or two before the schedule appointment date or both.
    • Inform beneficiaries if they routinely fail to keep an appointment or give advance notice when they need to cancel an appointment, you may no longer accept them as a patient.
    • Schedule patients to allow for those who are likely to miss a scheduled appointment.
    • If a beneficiary misses an appointment, allow him or her to come in as a “walk-in” and wait for a time in the dentist’s schedule to become available.
  • Can providers bill Medicaid beneficiaries for missed appointments?

    According to the Center for Medicare and Medicaid Services (CMS) and the Oral Health Technical Advisory Group, a provider can not bill a Medicaid beneficiary for missed appointments. Current Medicaid policy does not allow for billing beneficiaries for missed appointments because a service was not provided; therefore, no reimbursement is available. In addition, missed appointments are not a reimbursable Medicaid service, but are considered a part of providers’ overall cost of doing business. In no case may providers impose separate charges to beneficiaries.

  • What should I do if I submitted a prior authorization (PA) and the claim still denies?

    First review the claim to ensure you submitted it correctly. If the claim was filed correctly send a copy of the claim with the supporting documentation to Xerox advising them that the claim denied incorrectly.

  • Can I appeal a prior authorization (PA) if it is denied?

    Yes, if you have additional information that supports the medical necessity of the procedure.

  • What is the status of my prior authorization (PA)?

    You may use the eQHealth Solutions website to retrieve current information regarding your PA. Upon completion of the review the system will be updated to reflect the decision.

  • Is there an age limit for the procedure code?

    Some dental codes have age limits. Provides should review their fee schedule to determine if the procedure code is billable for the patient.

  • Is a radiograph required when a dental prior authorization (PA) is submitted?

    The following codes require radiographs D2750 – D2752, D5211, D5212 and D9940.  As well as all Othodontic related services D8080, D8670 and D8999.

  • Is a Prior Authorization (PA) required for dental procedures?

    A prior authorization is needed for all orthodontic services and certain dental procedure. Providers should review the fee schedule to determine if the procedure requires a PA.

Medical Supplies

  • How do providers bill dates that span months?

    If a provider’s date-of-service is Jan. 15, 2009 through Feb. 15, 2009, two separate claims will have to be submitted. The first claim should include the dates of service Jan. 15, 2009 through Jan. 31, 2009 and the second claim should include dates of service Feb. 1, 2009 through Feb. 15, 2009.

  • How do providers bill claims when the supply codes are manually priced?

    All manually priced medical supplies require the MSRP or an invoice to be submitted along with the claims. If you submit your claims electronically, you will need to mail or fax the MSRP or invoice to Xerox before your claims can be processed. If you submit your claims via the web portal, you can upload the MSRP or invoice to attach to your claims. If you submit your claims on hardcopy, you will need to attach the MSRP or invoice to your claims and mail or fax them to Xerox for processing at (601) 206-3119.

  • How do providers handle TAN’s received prior to Jan. 1, 2009 and extend beyond that date?

    Providers should bill those claims without a TAN if the date-of-service is Jan. 1, 2009 or after.

  • If providers have prescriptions dated prior to Jan. 1, 2009, will a new prescription be required on Jan. 1, 2009?

    No. The prescription received prior to Jan. 1, 2009 does not have to be updated until 12 months after the original prescription date.

  • How often does a prescription have to be updated?

    The prescription has to be updated every 12 months.

  • How often does the CMN/POC form have to be updated?

    Providers must update this form every 12 months.

  • Which medical supply codes do not require prior authorization?

    The fee schedules on Medicaid’s website under the Provider tab, list all the supply codes whether they require a prior authorization or not.

  • Is a prior authorization required for medical supplies?

    As of Jan. 1, 2009, medical supplies no longer require prior authorization with the exception of diapers and underpads. Providers should follow the same process and procedures set forth prior to Jan. 1, 2009 when requesting prior authorization for diapers and underpads.

MississippiCAN

  • Can a beneficiary enrolled in MississippiCAN change from one CCO to another?

    During the initial 90-day enrollment period, a member can change CCOs without restriction. Also, there will be an open enrollment period each year in which a member can change CCOs without restriction.

  • Will beneficiaries be allowed to disenroll from a plan if required specialized services are not available?

    Various “for cause” reasons for disenrollment will be allowed, such as: providers that do not (for religious or moral reasons) offer needed services; not all related services are available in the plan’s network; or the plan lacks providers experienced in dealing with the enrollee’s health care needs.

  • Can a CCO disenroll a beneficiary because their care is costing too much?

    A CCO cannot disenroll a beneficiary because of an adverse change in the beneficiary’s health status or because of the beneficiary’s utilization of medical services.

  • Will beneficiaries who are enrolled in the MississippiCAN program be responsible for copays?

    There will be no copayments for MississippiCAN members for services provided by the CCOs.

  • Will CCOs be marketing to beneficiaries?

    CCOs are not allowed to market directly to Medicaid beneficiaries prior to enrollment. All marketing of potential enrollees will be handled by the Division of Medicaid. The Division will be providing information about choice of CCOs and enrolling beneficiaries into their chosen CCO.

  • What if a beneficiary has a problem with the CCO?

    Each CCO has a grievance procedure. If the issue is not resolved satisfactorily through the CCO, the beneficiary has the right to a State Fair Hearing.

  • If a CCO does not authorize a covered service, will regular Medicaid pay for the CCO covered service?

    No.

  • What is the benefit of a beneficiary enrolling with a CCO?

    CCOs will be providing beneficiaries with specific care management and disease management for chronic conditions like diabetes, hypertension, HIV/AIDS, etc. Also, CCOs may offer extra benefits and other incentives.

  • Will beneficiaries get an identification card from the CCO when they enroll?

    Yes. Beneficiaries enrolled in a CCO will have an identification card from the CCO and a Medicaid identification card. It will be necessary to keep both cards.

  • If a beneficiary enrolls with a CCO, how will he or she get a ride to medical appointments if needed?

    Non-emergency transportation will continue to be provided by Medicaid. A beneficiary will call 1-866-331-6007 to make arrangements for a ride.

  • Will prescription drugs be one of the benefits offered by the CCOs?

    Yes.

  • Can a beneficiary choose a specialist as a PCP?

    Beneficiaries with disabling conditions, chronic illnesses, or children with special care needs may request that their PCP be a specialist.

  • Can a beneficiary enrolled in the MississippiCAN program continue to receive care from a provider who does not participate in any of the plans?

    Providers who do not join a CCO network will require authorization from the CCO for payment of services provided to a beneficiary enrolled in MississippiCAN. A beneficiary enrolled in the MississippiCAN program should seek treatment from a provider in the CCO network.

  • Will MississippiCAN replace a beneficiary’s Medicaid?

    The MississippiCAN program is part of the Mississippi Medicaid program. It is not a replacement.

  • Can a beneficiary in MississippiCAN change PCPs?

    Yes. The beneficiary should call Member Services of the CCO with which they are enrolled.

  • Will beneficiaries be allowed to select their primary care provider (PCP) within a CCO?

    Each beneficiary will be allowed to choose their PCP from the CCO network to the extent possible, reasonable and appropriate. If the beneficiary does not choose an available PCP, the CCO may assign the beneficiary a PCP.

  • Will beneficiaries have freedom of choice in determining the best plan for their needs?

    Yes.

  • How will it be ensured that beneficiaries who are blind or those with low literacy or limited English proficiency obtain information necessary to choose a plan?

    Enrollment information and materials will be developed to ensure all beneficiaries, including those with special needs, are fully informed of their choice of plans.

  • What consumer protections are being included in the MississippiCAN program?

    Members’ rights and protections are required, including the right to:

    • Receive needed information about the program;
    • Be treated with respect, dignity and privacy;
    • Receive information on available treatment options; participate in health care decisions;
    • Request copies of medical records; and
    • Be furnished services with an adequate delivery network, timely access, coordination and continuity of care, and other specified standards.

    Members’ protections will also be provided through access standards, care coordination requirements, quality management programs and detailed grievance and appeals procedures.

  • If a beneficiary enrolled in the MississippiCAN program loses eligibility, does he or she have to choose a CCO again?

    If the beneficiary regains Medicaid eligibility within 60 days, he or she will be reassigned to the same CCO he or she was in before. If the beneficiary regains Medicaid eligibility after 60 days, he or she will go through the complete enrollment process again.

  • If a beneficiary opts out of the MississippiCAN program but later decides that he or she wants join, does he or she have to wait until the next open enrollment period?

    No. A beneficiary in an eligible category may join at any time. A beneficiary may print the MississippiCAN enrollment form from the website or may call toll-free 1-800-421- 2408 and ask to be mailed a MississippiCAN enrollment packet.

  • Is it mandatory for beneficiaries to enroll in the MississippiCAN program?

    Although enrollment in the program is voluntary, the Division of Medicaid strongly encourages beneficiary participation. The MississippiCAN program will connect beneficiaries to a medical home and provide comprehensive care management programs for these targeted populations.

  • Can any Medicaid beneficiary enroll in the MississippiCAN program?

    Only Medicaid beneficiaries in the eligibility groups listed below can enroll in the MississippiCAN program.

    • Supplemental Security Income (SSI)
    • Disabled Child at Home
    • Working Disabled
    • Department of Human Services Foster Care
    • Breast/Cervical Group

Outpatient Therapy

  • Does DOM cover outpatient physical therapy, occupational therapy and/or speech-language pathology services in multiple settings?

    Beneficiaries under age twenty-one may receive medically necessary outpatient therapy services in more than one setting if the services are coordinated and not duplicate in nature. The following information must be submitted with the pre-certification request:

    • Goals and objectives from both therapists
    • A written statement signed and dated by the original/initial therapy provider confirming the coordination of services
  • Does DOM reimburse hospitals for therapy services provided by salaried/contracted therapists at an offsite location?

    According to current DOM policy, if contracted or employed hospital employees provide services offsite and outside of  the outpatient hospital departments, the hospital may not bill a charge on the UB04 claim format as an outpatient hospital service. This includes, but is not limited to, sites such as the beneficiary’s home, daycare centers, schools, skilled nursing facilities, physician clinics or therapy clinics. Such places of service are not in the hospital’s outpatient departments and do not qualify as an outpatient hospital service.

  • Does DOM policy provide coverage for maintenance therapy?

    No. Maintenance therapy consists of activities that preserve the patient’s present level of function and prevent regression of that function.  Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, and are not covered by DOM.

  • Does DOM cover therapy aides and assistants?

    DOM will cover services provided by physical therapy assistants (PTA’s) and certified occupational therapy assistants (COTA’s) only in the outpatient department of a hospital. PTA’s and COTA’s must be under direct supervision of a state-licensed therapist of the same discipline. Services provided by physical and/or occupational therapy aides are not covered.

    DOM does not cover services provided by speech-language pathology assistants and/or aides regardless of the level of supervision.

  • Are providers allowed to add attachments to the standard forms?

    Providers must complete the standard forms. If the provider uses all the space provided on a form and needs to continue, the provider may write “see attachment” and add the Additional Medical Information Form.   The provider may not add attachments in lieu of completing the forms.

  • Does DOM and UM/QIO plan to develop an electronic process for submitting the requests?

    Yes. It is anticipated that this technology can be adapted for pre-certification of therapy services. UM/QIO and DOM plans to run a pilot program first followed by full implementation of the technology in 2010.

  • Why does DOM and UM/QIO require that prescribing providers/therapists utilize their standard forms to submit pre-certification requests to UM/QIO ?

    DOM made the decision to develop and require use of the standard forms to:

    1. ensure consistency in reporting,
    2. respond to provider requests to define the information needed for the pre-certification request,
    3. assist in provider education, and
    4. expedite review process at UM/QIO .

    The development of the forms was a joint effort between DOM and UM/QIO with input from therapists working with UM/QIO .

  • What are the timelines for UM/QIO providing a response to a request?

    For pre-certification and concurrent requests, UM/QIO will complete the review within two business days of receipt of all necessary information. For example, if a pre-certification/concurrent request is received on Monday, the provider will have a response by close of business Wednesday (day two).

    For retrospective requests, UM/QIO will complete the review within 20 business days of receipt of all necessary information. For example, if a retrospective request is received on April 3, 2009, the provider will have a response by close of business May 1, 2009.

    If a pre-certification request is pended for additional administrative information (intake level) or additional information (first level review), the provider has three business days to submit the information. The receipt date of the request is updated when the information is received.

    If a concurrent request is pended for additional administrative information (intake level), the provider has three business days to submit the information. If a concurrent request is pended for additional information (first level review), the provider has one business day to submit the information. The receipt date of the request is updated when the information is received.

    If a pre-certification/concurrent request is pended by the physician review team, the provider has one business day to submit the information. The receipt date of the request is updated when the information is received.

    If a retrospective request is pended for additional information (first level review), the provider has ten business days to submit the information. The receipt date of the request is updated when the information is received.

    If a review is pended at multiple levels, such as intake, (nurse first level review), physician, the time frame is extended accordingly.

  • Is UM/QIO authorized to reduce frequency and length of services without getting the prescribing physician’s approval?

    Yes. This is consistent with the role of utilization management companies who are contracted to approve services based on documented medical necessity and application of criteria and policies.

  • Are National Guidelines available to providers?

    DOM and UM/QIO  do not provide copies of the National Guidelines to providers. The guidelines are a commercially available product. For additional information, go to the National Guideline Clearinghouse website.

  • Are the National Guidelines applicable to only adults?

    No, the National Guidelines are not specific to adults only.  Each review is carefully and individually evaluated in accordance with standards and the growth and development process for children.  Both DOM and UM/QIO are focused on ensuring children receive medically necessary services.

  • What criteria are used for medical necessity?

    DOM has authorized use of the National Guidelines as a tool to be used in the review of medical necessity. The National Guidelines are evidence-based tools that reflect current best practices for the actual working environment of today’s healthcare organization.

  • Who reviews pre-certification requests?

    The review process is handled through the Utilization Management and Quality Improvement Organization (UM/QIO). Reviews are based on information provided by the prescribing providers and therapists, medical necessity criteria and DOM policies.  When conducting reviews, UM/QIO utilizes a professional staff consisting of registered nurses, therapists and physicians.

  • If the number of approved units for a pre-certified period of time is not used, can the therapy provider carry over the unused units to another time period?

    No, units cannot be carried over from one period of time to another.  The provider must submit a concurrent request if additional therapy is required.  Providers should submit documentation explaining why previously approved units were not utilized (e.g., child is ill and unable to participate in therapy).  The information will assist UM/QIO  in making determinations for further coverage

  • How can the provider find out if a code that does not require pre-certification is covered?

    Providers may contact the Xerox Call Center toll-free at 1-800-884-3222 or their respective provider representative.  Providers may also access the Mississippi Envision web portal. Select the provider drop- down, go to fee schedules and select the interactive fee schedule.

  • Can a provider bill for a therapy code not on the list if the service is covered under Mississippi Medicaid?

    Yes, if it is medically necessary and is covered by DOM.

  • Does DOM require pre-certification for all therapy codes?

    No.  To obtain a list of codes that require pre-certification, providers should refer to the UM/QIO  website. Follow the provider manual link. The codes requiring pre-certification are listed in the Outpatient and School Health Related Occupational, Physical and Speech Therapy Provider Manual.

  • What is the role of Utilization Management and Quality Improvement Organization (UM/QIO)?

    DOM contracted with a UM/QIO  to perform pre-certification and quality review for outpatient physical therapy, occupational therapy and speech-language pathology services.

  • Why did the Division of Medicaid (DOM) implement pre-certification requirements for outpatient physical, occupational, and speech-language pathology (speech therapy) services?

    It is DOM’s responsibility to be a prudent purchaser of quality health care and to ensure that benefits are provided for medically necessary services.

Providers

  • If a CCO does not authorize a covered service, will regular Medicaid pay for the CCO covered service?

    No.

  • Will beneficiaries get an identification card from the CCO when they enroll?

    Yes. Beneficiaries enrolled in a CCO will have an identification card from the CCO and a Medicaid identification card. It will be necessary to keep both cards.

  • Does DOM cover outpatient physical therapy, occupational therapy and/or speech-language pathology services in multiple settings?

    Beneficiaries under age twenty-one may receive medically necessary outpatient therapy services in more than one setting if the services are coordinated and not duplicate in nature. The following information must be submitted with the pre-certification request:

    • Goals and objectives from both therapists
    • A written statement signed and dated by the original/initial therapy provider confirming the coordination of services
  • Does DOM reimburse hospitals for therapy services provided by salaried/contracted therapists at an offsite location?

    According to current DOM policy, if contracted or employed hospital employees provide services offsite and outside of  the outpatient hospital departments, the hospital may not bill a charge on the UB04 claim format as an outpatient hospital service. This includes, but is not limited to, sites such as the beneficiary’s home, daycare centers, schools, skilled nursing facilities, physician clinics or therapy clinics. Such places of service are not in the hospital’s outpatient departments and do not qualify as an outpatient hospital service.

  • Does DOM policy provide coverage for maintenance therapy?

    No. Maintenance therapy consists of activities that preserve the patient’s present level of function and prevent regression of that function.  Maintenance programs do not require the professional skills of a licensed therapy provider, are not considered medically necessary, and are not covered by DOM.

  • Does DOM cover therapy aides and assistants?

    DOM will cover services provided by physical therapy assistants (PTA’s) and certified occupational therapy assistants (COTA’s) only in the outpatient department of a hospital. PTA’s and COTA’s must be under direct supervision of a state-licensed therapist of the same discipline. Services provided by physical and/or occupational therapy aides are not covered.

    DOM does not cover services provided by speech-language pathology assistants and/or aides regardless of the level of supervision.

  • Are providers allowed to add attachments to the standard forms?

    Providers must complete the standard forms. If the provider uses all the space provided on a form and needs to continue, the provider may write “see attachment” and add the Additional Medical Information Form.   The provider may not add attachments in lieu of completing the forms.

  • Does DOM and UM/QIO plan to develop an electronic process for submitting the requests?

    Yes. It is anticipated that this technology can be adapted for pre-certification of therapy services. UM/QIO and DOM plans to run a pilot program first followed by full implementation of the technology in 2010.

  • Why does DOM and UM/QIO require that prescribing providers/therapists utilize their standard forms to submit pre-certification requests to UM/QIO ?

    DOM made the decision to develop and require use of the standard forms to:

    1. ensure consistency in reporting,
    2. respond to provider requests to define the information needed for the pre-certification request,
    3. assist in provider education, and
    4. expedite review process at UM/QIO .

    The development of the forms was a joint effort between DOM and UM/QIO with input from therapists working with UM/QIO .

  • What are the timelines for UM/QIO providing a response to a request?

    For pre-certification and concurrent requests, UM/QIO will complete the review within two business days of receipt of all necessary information. For example, if a pre-certification/concurrent request is received on Monday, the provider will have a response by close of business Wednesday (day two).

    For retrospective requests, UM/QIO will complete the review within 20 business days of receipt of all necessary information. For example, if a retrospective request is received on April 3, 2009, the provider will have a response by close of business May 1, 2009.

    If a pre-certification request is pended for additional administrative information (intake level) or additional information (first level review), the provider has three business days to submit the information. The receipt date of the request is updated when the information is received.

    If a concurrent request is pended for additional administrative information (intake level), the provider has three business days to submit the information. If a concurrent request is pended for additional information (first level review), the provider has one business day to submit the information. The receipt date of the request is updated when the information is received.

    If a pre-certification/concurrent request is pended by the physician review team, the provider has one business day to submit the information. The receipt date of the request is updated when the information is received.

    If a retrospective request is pended for additional information (first level review), the provider has ten business days to submit the information. The receipt date of the request is updated when the information is received.

    If a review is pended at multiple levels, such as intake, (nurse first level review), physician, the time frame is extended accordingly.

  • Is UM/QIO authorized to reduce frequency and length of services without getting the prescribing physician’s approval?

    Yes. This is consistent with the role of utilization management companies who are contracted to approve services based on documented medical necessity and application of criteria and policies.

  • Are National Guidelines available to providers?

    DOM and UM/QIO  do not provide copies of the National Guidelines to providers. The guidelines are a commercially available product. For additional information, go to the National Guideline Clearinghouse website.

  • Are the National Guidelines applicable to only adults?

    No, the National Guidelines are not specific to adults only.  Each review is carefully and individually evaluated in accordance with standards and the growth and development process for children.  Both DOM and UM/QIO are focused on ensuring children receive medically necessary services.

  • What criteria are used for medical necessity?

    DOM has authorized use of the National Guidelines as a tool to be used in the review of medical necessity. The National Guidelines are evidence-based tools that reflect current best practices for the actual working environment of today’s healthcare organization.

  • Who reviews pre-certification requests?

    The review process is handled through the Utilization Management and Quality Improvement Organization (UM/QIO). Reviews are based on information provided by the prescribing providers and therapists, medical necessity criteria and DOM policies.  When conducting reviews, UM/QIO utilizes a professional staff consisting of registered nurses, therapists and physicians.

  • If the number of approved units for a pre-certified period of time is not used, can the therapy provider carry over the unused units to another time period?

    No, units cannot be carried over from one period of time to another.  The provider must submit a concurrent request if additional therapy is required.  Providers should submit documentation explaining why previously approved units were not utilized (e.g., child is ill and unable to participate in therapy).  The information will assist UM/QIO  in making determinations for further coverage

  • How can the provider find out if a code that does not require pre-certification is covered?

    Providers may contact the Xerox Call Center toll-free at 1-800-884-3222 or their respective provider representative.  Providers may also access the Mississippi Envision web portal. Select the provider drop- down, go to fee schedules and select the interactive fee schedule.

  • Can a provider bill for a therapy code not on the list if the service is covered under Mississippi Medicaid?

    Yes, if it is medically necessary and is covered by DOM.

  • Does DOM require pre-certification for all therapy codes?

    No.  To obtain a list of codes that require pre-certification, providers should refer to the UM/QIO  website. Follow the provider manual link. The codes requiring pre-certification are listed in the Outpatient and School Health Related Occupational, Physical and Speech Therapy Provider Manual.

  • What is the role of Utilization Management and Quality Improvement Organization (UM/QIO)?

    DOM contracted with a UM/QIO  to perform pre-certification and quality review for outpatient physical therapy, occupational therapy and speech-language pathology services.

  • Why did the Division of Medicaid (DOM) implement pre-certification requirements for outpatient physical, occupational, and speech-language pathology (speech therapy) services?

    It is DOM’s responsibility to be a prudent purchaser of quality health care and to ensure that benefits are provided for medically necessary services.

  • What are my health facts?

    Your health facts mean your Protected Health Information (PHI). Your PHI is information that identifies you, like your name and date of birth. PHI is also information about your health kept in your health care records.

  • How do providers bill dates that span months?

    If a provider’s date-of-service is Jan. 15, 2009 through Feb. 15, 2009, two separate claims will have to be submitted. The first claim should include the dates of service Jan. 15, 2009 through Jan. 31, 2009 and the second claim should include dates of service Feb. 1, 2009 through Feb. 15, 2009.

  • How do providers bill claims when the supply codes are manually priced?

    All manually priced medical supplies require the MSRP or an invoice to be submitted along with the claims. If you submit your claims electronically, you will need to mail or fax the MSRP or invoice to Xerox before your claims can be processed. If you submit your claims via the web portal, you can upload the MSRP or invoice to attach to your claims. If you submit your claims on hardcopy, you will need to attach the MSRP or invoice to your claims and mail or fax them to Xerox for processing at (601) 206-3119.

  • How do providers handle TAN’s received prior to Jan. 1, 2009 and extend beyond that date?

    Providers should bill those claims without a TAN if the date-of-service is Jan. 1, 2009 or after.

  • If providers have prescriptions dated prior to Jan. 1, 2009, will a new prescription be required on Jan. 1, 2009?

    No. The prescription received prior to Jan. 1, 2009 does not have to be updated until 12 months after the original prescription date.

  • How often does a prescription have to be updated?

    The prescription has to be updated every 12 months.

  • How often does the CMN/POC form have to be updated?

    Providers must update this form every 12 months.

  • Which medical supply codes do not require prior authorization?

    The fee schedules on Medicaid’s website under the Provider tab, list all the supply codes whether they require a prior authorization or not.

  • Is a prior authorization required for medical supplies?

    As of Jan. 1, 2009, medical supplies no longer require prior authorization with the exception of diapers and underpads. Providers should follow the same process and procedures set forth prior to Jan. 1, 2009 when requesting prior authorization for diapers and underpads.

  • What can a provider do to minimize missed appointments?

    These are suggestions only; they do not represent Medicaid policy. It is important to treat all Medicaid beneficiaries in the same manner as other non-Medicaid patients are treated:

    • Confirm appointments prior to the date of the appointment by sending a post card or calling a day or two before the schedule appointment date or both.
    • Inform beneficiaries if they routinely fail to keep an appointment or give advance notice when they need to cancel an appointment, you may no longer accept them as a patient.
    • Schedule patients to allow for those who are likely to miss a scheduled appointment.
    • If a beneficiary misses an appointment, allow him or her to come in as a “walk-in” and wait for a time in the dentist’s schedule to become available.
  • Can providers bill Medicaid beneficiaries for missed appointments?

    According to the Center for Medicare and Medicaid Services (CMS) and the Oral Health Technical Advisory Group, a provider can not bill a Medicaid beneficiary for missed appointments. Current Medicaid policy does not allow for billing beneficiaries for missed appointments because a service was not provided; therefore, no reimbursement is available. In addition, missed appointments are not a reimbursable Medicaid service, but are considered a part of providers’ overall cost of doing business. In no case may providers impose separate charges to beneficiaries.

  • What should I do if I submitted a prior authorization (PA) and the claim still denies?

    First review the claim to ensure you submitted it correctly. If the claim was filed correctly send a copy of the claim with the supporting documentation to Xerox advising them that the claim denied incorrectly.

  • Can I appeal a prior authorization (PA) if it is denied?

    Yes, if you have additional information that supports the medical necessity of the procedure.

  • What is the status of my prior authorization (PA)?

    You may use the eQHealth Solutions website to retrieve current information regarding your PA. Upon completion of the review the system will be updated to reflect the decision.

  • Is there an age limit for the procedure code?

    Some dental codes have age limits. Provides should review their fee schedule to determine if the procedure code is billable for the patient.

  • Is a radiograph required when a dental prior authorization (PA) is submitted?

    The following codes require radiographs D2750 – D2752, D5211, D5212 and D9940.  As well as all Othodontic related services D8080, D8670 and D8999.

  • Is a Prior Authorization (PA) required for dental procedures?

    A prior authorization is needed for all orthodontic services and certain dental procedure. Providers should review the fee schedule to determine if the procedure requires a PA.

Technology

  • What are my health facts?

    Your health facts mean your Protected Health Information (PHI). Your PHI is information that identifies you, like your name and date of birth. PHI is also information about your health kept in your health care records.